Primary care provider approaches to preventive health delivery: a qualitative study

Primary Care: Its Pokemon Moment

Primary care in the United States is undergoing bursts of evolution in response to health system stresses, changing demographics, and expansion of risk and value-based reimbursement structures. The impact of primary care remains substantive and associated with improved population health. However, the spectrum of services, the nature of the physicians involved and new ways of including the patient in her, or his own care suggests that a new definition of primary care be considered, and patient expectations be heeded and understood. Evolutionary bursts yield new traits and in primary care, they are spawning new care models with significant implications for general internal medicine, internal medicine/pediatrics trained individuals and medicine subspecialties given the focus of these models on Medicare Advantage. Ultimately, changes in reimbursement and creative incentives will be two factors among many that will solidify the next stage of primary care in the United States.

Follow-Up Timing After Discharge and Suicide Risk Among Patients Hospitalized With Psychiatric Illness

Importance

Although early outpatient follow-up after psychiatric inpatient discharge may prevent suicide, the association between early follow-up care and a reduced risk of suicide after discharge has not been fully explored.

Objectives

To investigate outpatient follow-up care after psychiatric inpatient discharge and determine whether the timing of the first outpatient follow-up is associated with a reduced risk of suicide.

Design, Setting, and Participants

This population-based, retrospective cohort study used the National Health Claim Database from 2017 to 2018 in Korea. Patients were observed until December 31, 2021, to confirm the occurrence of suicide. The study population included all patients aged 18 years or older who were newly admitted to hospitals with psychiatric illness except for dementia from January 1, 2017, to December 31, 2018. Statistical analysis was performed from January to May 2023.

Exposure

The timing of the first mental health outpatient care follow-up within 30 days after discharge.

Main Outcomes and Measures

The outcome of interest was suicide after hospital discharge. The timing of the first follow-up visit was observed within 30 days after discharge. The Cox proportional hazard model was used to explore the association between the risk of suicide and the timing of outpatient follow-up.

Results

Of the 76 462 patients admitted to hospitals from 2017 to 2018, 225 (52.6%) were male; 21 313 (27.9%) had a primary diagnosis of substance use disorder, 17 608 (23.0%) had schizophrenia, and 15 018 (19.6) had depression; mean (SD) age was 46.4 (16.3) years. A total of 49 319 patients (64.5%) received follow-up outpatient care within 30 days of discharge. The mean (SD) follow-up period was 30.8 (20.2) months, and 1536 patients died of suicide during the study period. The hazard ratio for suicide risk in patients who received outpatient care within 7 days compared with those who did not receive any care within 30 days after discharge was 0.82 (95% CI, 0.80-0.83). The earlier the time of outpatient follow-up care, the lower the risk of suicide for those with substance use disorder, schizophrenia, bipolar disorder, and depression.

Conclusions and Relevance

In this cohort study of patients with psychiatric illness, early follow-up outpatient care after discharge was associated with a lower risk of suicide. These results suggest that those at high risk of suicide during hospitalization need intensive follow-up immediately after discharge.

Primary Care Pracitioner Perspectives on the Role of Primary Care in Dementia Diagnosis and Care

Importance

Although the barriers to dementia care in primary care are well characterized, primary care practitioner (PCP) perspectives could be used to support the design of values-aligned dementia care pathways that strengthen the role of primary care.

Objective

To describe PCP perspectives on their role in dementia diagnosis and care.

Design, Setting, and Participation

In this qualitative study, interviews were conducted with 39 PCPs (medical doctors, nurse practitioners, and doctors of osteopathic medicine) in California between March 2020 and November 2022. Results were analyzed using thematic analysis.

Main Outcomes and Measures

Overarching themes associated with PCP roles in dementia care.

Results

Interviews were conducted with 39 PCPs (25 [64.1%] were female; 16 [41%] were Asian). The majority (36 PCPs [92.3%]) reported that more than half of their patients were insured via MediCal, the California Medicaid program serving low-income individuals. Six themes were identified that convey PCPs' perspectives on their role in dementia care. These themes focused on (1) their role as first point of contact and in the diagnostic workup; (2) the importance of long-term, trusting relationships with patients; (3) the value of understanding patients' life contexts; (4) their work to involve and educate families; (5) their activities around coordinating dementia care; and (6) how the care they want to provide may be limited by systems-level constraints.

Conclusions and Relevance

In this qualitative study of PCP perspectives on their role in dementia care, there was alignment between PCP perspectives about the core values of primary care and their work diagnosing and providing care for people living with dementia. The study also identified a mismatch between these values and the health systems infrastructure for dementia care in their practice environment.

Shedding light on pharmacists' knowledge of kidney stones' etiology and treatment

Background

The recurring nature of kidney stones (KS) makes it difficult to control and treat. Patients' education plays a part in reducing disease recurrence. Pharmacists participate in the healthcare services through educating patients with kidney stones about KS preventive measures and medications that greatly reduce the disease frequency and the treatment cost. Insufficient pharmacists' knowledge may affect the services' quality and result in misuse of KS medications.

Objectives

To evaluate the pharmacists' level of knowledge to provide adequate information about KS preventive measures, medications, and treatments for patients with kidney stones in Jordan.

Methods

An online descriptive survey was distributed to pharmacists to assess their knowledge about KS causes, prevention, and treatment. The results were analyzed using the SPSS software.

Results

There were 393 pharmacists participated in this study. Pharmacists demonstrated an overall intermediate level of knowledge about KS. They showed an excellent level of knowledge regarding KS types and etiology, an intermediate level of knowledge about KS preventive measures and treatment, and poor knowledge about home remedies and drugs that promote KS formation.

Conclusion

Pharmacists knowledge about KS management through diet and medications need to be improved. This could be through focusing on pharmacists' training for the effective implementation of knowledge in the clinical practice. Adopting guidelines by pharmacists may reduce the risk of KS recurrence and provide pharmacist-led patient education about KS management in hospitals and community pharmacies.

How Do Family Physicians Perceive Their Role in Providing Pre-exposure Prophylaxis for HIV Prevention?-An Online Qualitative Study in Flanders, Belgium

Introduction:

In Belgium, the provision of pre-exposure prophylaxis (PrEP) for HIV prevention is centralized in specialized HIV clinics. Engaging family physicians in PrEP care could help scale-up its delivery and reach underserved populations. The objective of this study was to gain insight into family physicians' self-perceived roles in providing PrEP.

Methods

We conducted 16 online group discussions with a total of 105 Flemish family physicians, between November 2020 and February 2021. A brief online questionnaire assessed their socio-demographics and experience with sexual health. We analyzed verbatim transcribed data using a grounded theory approach.

Results

Despite limited awareness and experience, participants reported a high willingness to be more actively involved in PrEP care. Four potential roles for the family physician in PrEP care were identified: acting as low-threshold entry point for advice; opportunistic case finding of PrEP candidates; initiating appropriate care for PrEP-eligible clients; and ensuring high-quality follow-up care for PrEP users. Participants framed each of these roles within their current activities and responsibilities as primary care providers. Yet, participants differed in their views on the concrete operationalization of these roles, and in the extent of their involvement in PrEP. Particular challenges were a lack of experience with antiretrovirals, perceived limited exposure to clients at high HIV risk, and a lack of expertise and resources to conduct time-intensive risk assessments and counseling related to PrEP.

Conclusion

Belgian family physicians demonstrated a keen willingness to be involved in PrEP care, but had differing views on the practical implementation into their practices. Providing tailored training on sexual health and PrEP, and investing in collaboration between primary and secondary care, could optimize the integration of PrEP in the primary care practice.

Health Care Providers' Perspectives on COVID-19 and Medical Neglect in Children with Life-Threatening Complex Chronic Conditions

PURPOSE

Little is known regarding medical neglect in children with Life-Threatening Complex Chronic Conditions (LT-CCCs). We examined the impact of COVID-19 on concern for medical neglect in this population.

METHODS

Qualitative interview study of multi-disciplinary health care providers (HCPs) from critical care, palliative care, and complex care services on the topic of medical neglect in children with LT-CCCs. We used inductive thematic analysis to generate themes. Findings presented herein are derived from a sub-analysis of the larger study that focused specifically on discussion of COVID-19 by HCPs.

RESULTS

9 of the 20 HCPs interviewed mentioned COVID-19 as influencing situations of potential medical neglect. These 9 represent all disciplines and teams. Interviewees reported COVID-19 increased burden on parents and likelihood of medical neglect due to: 1) Familial distancing from medical and social support and, 2) Changes to medical care delivery that impaired the medical community's ability to engage and support families.

CONCLUSIONS

The COVID-19 pandemic has exposed the fragility of the medical and social systems that supports families of children with LT-CCCs. These findings are consistent with previous literature that suggest that the COVID-19 pandemic has increased the risk for child maltreatment. It additionally highlights the vulnerability of this patient population.